Charity Services & Pro-Bono Summary​​

• Pro-bono services and sliding fee scales are offered based on Medicaid status and/or severe financial hardship (e.g., unemployment, medical necessity), subject to availability, with a written application and flexible documentation (e.g., proof of income loss, utility bills, pay stubs). These services comply with:

• Section 1557 of the Affordable Care Act (42 U.S.C. § 18116), ensuring no discrimination based on race, color, national origin, sex, age, or disability;

• The No Surprises Act, providing Good Faith Estimates and clear explanation of insurances accepted, payment arrangement expectations, payment waiver expectations, refund policies, collection efforts, and timelines for arbitration efforts due to payment-related concerns.

• Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d), preventing discrimination based on race, color, or national origin;

• Age Discrimination Act of 1975 (42 U.S.C. §§ 6101-6107), ensuring access regardless of age;

• Americans with Disabilities Act (42 U.S.C. §§ 12101 et seq.), providing reasonable accommodations;

• Ohio Revised Code § 4757, upholding licensing and ethical nondiscrimination standards in sliding fee scale and pro-bono offering agreements, GFE transparency.

• Federal law provides that individuals eligible for medical assistance may obtain services from any qualified person who undertakes to provide them (42 U.S.C. § 1396a(a)(23)). This practice operates on a cash-pay and voluntary charity (pro-bono) basis outside the Medicaid program. No services are billed to Medicaid, and no claim is submitted on behalf of any client.

• Clients retain the freedom to choose their provider consistent with federal principles of patient choice. Pro-bono services are offered in accordance with this practice’s faith-based mission to serve individuals regardless of income, with no expectation of payment from the client. Consistent with the nature of voluntary charity care and the requirement under the Social Security Act that states use reasonable standards for determining income and resources (§ 1902(a)(17)), such services are generally not treated as income or a countable resource for Medicaid eligibility purposes.

• Free or pro bono psychotherapy and counseling services, including faith-based counseling, may be offered by the Provider to individuals who voluntarily elect to receive them. Such services are offered independently and without any requirement, condition, or connection to the provision of any other item or service for which payment may be made, in whole or in part, under Medicaid, or any other federal health care program.

• Under 42 C.F.R. § 1003.110, certain offers or transfers of items or services for free or less than fair market value are generally excluded from the definition of “remuneration” when they are not tied to the provision of other items or services reimbursed in whole or in part by a Federal health care program. The Company structures its voluntary pro-bono psychotherapy as standalone charity care, independent of any Federal or Company reimbursable service. The Company has structured its voluntary charity-care program with the intent of complying with applicable federal and state laws.

• To maintain clear clinical boundaries and ensure that voluntary pro-bono psychotherapy remains independent of any commercial services (Service Exclusivity), clients receiving pro-bono psychotherapy under this Agreement shall not concurrently receive Life Coaching or Athletic Coaching Wellness Services from the Company. This separation is intended to prevent dual relationships and to ensure that free clinical care is not used as an inducement or gateway to any paid services.

• Accordingly, the provision of standalone, free clinical counseling services by the Provider as described intends to structure free psychotherapy as standalone charity care, independent of any federally reimbursable service, to avoid inducement concerns.

• We provide clear service distinctions/service exclusivity to clients per federal consumer protection laws (15 U.S.C. §§ 41-58) and dual relationship guidelines (OAC Rule 4757-5-03.) 

• The Company makes no representation regarding the Client’s specific Medicaid eligibility status. The Client is encouraged to consult with a benefits specialist or county agency if they have questions about their own eligibility.

 

                                                                         

 

                                                                    Pro-Bono Services Agreement

1. Purpose and Scope
This Agreement applies only to approved pro-bono psychotherapy services. These services are clinical mental health counseling and psychotherapy only. This Agreement does not cover life coaching, athletic coaching, or any non-clinical services.
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2. Voluntary Charity Care Model and Legal Basis
The Company operates on a cash-pay and voluntary charity (pro-bono) care model only.
The Company does not bill Medicaid, Medicare, or any private insurance for psychotherapy services.
Pro-bono services under this Agreement are provided as voluntary charity care outside the Medicaid program.
No claim is submitted to Medicaid, Medicare, or any insurer on behalf of the Client.
These services are offered in accordance with the Company’s faith-based mission to serve individuals regardless of income, with no expectation of payment from the Client.
 
Federal law provides that individuals eligible for medical assistance may obtain services from any qualified person who undertakes to provide them (42 U.S.C. § 1396a(a)(23)).
Consistent with the nature of voluntary charity care and the requirement under the Social Security Act that states use reasonable standards for determining income and resources (§ 1902(a)(17)), the free psychotherapy services described in this Agreement are generally not treated as income or a countable resource for Medicaid eligibility purposes.
 
The Company makes no representation regarding the Client’s specific Medicaid eligibility status.
 
The Client is encouraged to consult with a benefits specialist or county agency if they have questions about their own eligibility.
 
3. Eligibility and Written Approval
Pro-bono services are available to clients who demonstrate significant financial hardship. Eligibility may be based on household income, Medicaid enrollment, recent job loss, medical or family hardship, or other indicia of inability to pay.
 
Approval of pro-bono services under this Agreement is:
Confirmed in writing by the Company.
Subject to the Company’s clinical appropriateness determination, provider availability, and overall pro-bono service capacity.
Not guaranteed for any specific number of sessions or duration.
Subject to periodic review.
 
The Client acknowledges that they requested pro-bono consideration and, where requested by the Company, provided documentation sufficient to verify financial need.
 
4. Services to Be Provided
The Client will receive individual psychotherapy services, typically one hour in length, at the frequency determined by the provider and Client.
The standard cash rate for these services is $45 per hour.
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Under this Agreement, the Client is not responsible for any fee, co-pay, deductible, or balance.
 
This Agreement covers only psychotherapy services specified.
Any additional services are governed by separate agreements and are not provided on a pro-bono basis under this Agreement.
 
5. No Expectation of Payment
No Insurance Billing
The Client acknowledges and agrees that:
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There is no expectation of payment from the Client for the services described in this Agreement; The Company will not submit a claim to Medicaid, Medicare, or any private insurer on the Client’s behalf.
The Client has not assigned benefits to the Company and will not seek reimbursement from any third-party payer for these services.
 
6. Review, Modification, and Termination
Pro-bono status may be reviewed periodically. The Client agrees to inform the Company of any material change in their financial circumstances. The Company reserves the right to modify or discontinue pro-bono services prospectively if:
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The Client no longer meets the financial hardship criteria.
The Company’s pro-bono capacity is reached.
The arrangement is no longer clinically or administratively appropriate.
The Client violates the terms of the Psychotherapy Services Agreement.
 
In the event of modification or termination, the Company will make reasonable efforts to provide advance notice and, where clinically appropriate, offer referral options.
 
The Client may discontinue pro-bono services at any time.
 
7. No Guarantee of Outcome
As stated in the Psychotherapy Services Agreement, psychotherapy does not guarantee any specific result. Fees are charged for professional time and services rendered; however, under this Agreement, no fee is charged.
 
If the Client is dissatisfied for any reason, the Company may, at its sole discretion, consider a goodwill accommodation. Any such accommodation does not constitute an admission of wrongdoing, negligence, or deficient care.
 
8. Confidentiality and Records
All information shared in psychotherapy remains protected under the confidentiality provisions described in the Psychotherapy Services Agreement and the HIPAA Notice of Privacy Practices. The absence of a fee does not alter the Company’s legal and ethical obligations regarding recordkeeping, privacy, or mandated reporting.
 
9. Integration with Master Agreement
This Agreement incorporates by reference the entire Psychotherapy Services Agreement, including provisions on confidentiality, limits of confidentiality, mandated reporting, client rights, grievance procedures, and telehealth. In the event of any conflict between this Agreement and the Psychotherapy Services Agreement, the terms more protective of the Client shall control.